Wiki Secondary Office visit Billed with Annual Physical

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jbreslin87

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I have a Physician who regularly bills an Annual Physical (99395-99397) with an Office visit E/M(99212-99215). I have tried telling him the differences as to when and how this should be done and for the most part, he has cut down on billing an office visit(99212-99215) with an Annual Physical(99395-99397).

One scenario that keeps coming up however is when a Patient comes in for an Annual Physical, had bloodwork beforehand, is found to have "Vitamin D Deficiency" and then the doctor bills for the Office visit on top of the physical for treating the Vitamin D Deficiency (same goes for B12).

I don't necessarily think that this qualifies as a significant, separate service but I'm not sure that I have a good argument against it. This doctor's argument is pretty much, 'well it's a new diagnosis and I wrote a prescription for it.' While I think about the patient receiving a copay or a deductible bill for this and trying to explain to them why they got a bill for Vitamin D deficiency. I think most people would be upset that they got billed separately for this but I can't tell if I'm looking at this scenario objectively or not.

Is my doctor right in billing separately for this service along with an Annual Physical or am I right in thinking that there just isn't enough work involved in diagnosis a Vitamin deficiency to bill separately for it?
 
I have 2 providers who do this often. It is warranted. When patients call to complain I tell them a condition was discussed - tests or RX or referrals given which is over and above a "well exam" If something found during the well exam this would warrant an office visit being billed.
Sure some patients will argue with you, but just tell them it's documented in the chart. Some patients will argue with you no matter what you do.

Some insurance carriers pay 50% of the allowables for this e/m code add on.

Also a lot of pretty healthy patients come in once a year for the well exam, get refills for their thyroid, birth control, viagra etc and aren't seen for another year. these patients should be responsible for an office visit.
 
If there is a problem addressed outside the Preventive elements, and medical necessity demands a M25 with an E/M, then you can bill it.

However, it would be good customer service to let the patient know before the provider delves into the problem part of the visit. From a patient's perspective, going from a "Free" visit, to have to pay $200-350 is pretty significant if they thought everything was covered under the preventive benefit.
 
Agreed. We actually have a section on our check-in sheets that explains this to patients. It's just a small box that explains that if you are here for a Annual Preventive Visit or Wellness Exam and things are discussed that fall outside of the parameters of those visits, the billing is separate and additional costs may incur. (those aren't the exact words but you get the idea) We find this to be helpful for both us and the patient.

And yes, our physician and NP will very commonly add an office visit to a preventive exam if labs results are reviewed and a new Rx is written. Just be sure the visit note has good documentation not just for reimbursement purposes but also for you, in the case that the patient calls as a result of getting a bill.
 
I'm going to vote no on the separate E/M for this

Reasoning:

An E/M has three separate parts or components. HISTORY, EXAM, MDM. Two of these three need to be met in order to qualify for "Separate" billing.

So if your performing a "Head to Toe" during a yearly/routine exam, and you find out later through blood work that the patient is low on D or B12, is there an additional and corresponding History or Exam component to go with it? My guess is that there is not. If there is not, I would not think that an additional charge is supported.

In order to bill out a separate E/M from the routine, the documentation needs to support two out of the three components.

If it does, then I agree.
 
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